IN THE UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF PENNSYLVANIA In Re: Debtor : : : : : : : : : : : Bankruptcy No. Chapter Movant v. Related to Document No. Hearing Date and Time: Respondent(s) APPEARANCE OF CHILD SUPPORT CREDITOR* OR REPRESENTATIVE I certify under penalty of perjury that I am a child support creditor* of the above-named debtor, or the authorized representative of such child support creditor, with respect to the child support obligations which is set out below. Name: Organization: Address: Telephone Number: X Date Summary of Child Support Obligation Amount of arrears: If Child Support has been assigned: Child Support Creditor* or Authorized Representative . $__________________________________. Amount of Support which is owed under assignments: $__________________________________. Amount currently due per week or per month: on a continuing basis: Amount owed primary child support Creditor (balance not assigned): $__________________________________. (per week) (per month) $__________________________________. Attach an itemized statement of account * Child support creditor includes both creditor to whom the debtor has a primary obligation to pay child support as well as any entity to whom such support has been assigned to the Federal Government or to any State or political subdivision of a State. PAWB Local Form 19 (07/13) American LegalNet, Inc. www.FormsWorkFlow.com